Ophthalmology Tissue Viability Link Nurse Tracy Culkin Assessment Chart for Wound Management Patient ID Label

For multiple wounds complete formal wound assessment for each wound. Add Inserts as needed.

Factors which could delay healing:(Please tick relevant box)

Immobility □ Poor Nutrition □ Diabetes □ Incontinence □

Respiratory/Circulatory Anaemia □ Medication □ Wound Infection □ Disease □

Inotropes □ Anti-Coagulants □ Oedema □ Steroids □

Chemotherapy □ Other………………… Allergies & Sensitivities………………………

Body Diagram

Front Back

Mark location with ‘X’ and number each wound

Type of Wound Total number & duration of each type of wound Leg Ulcer …………………………………..

Surgical Wound ……………………………….

Diabetic Ulcer ………………………….…

Pressure Ulcer ………………………………..

Other, specify ………………………………

Feet Diagram

Right Left

Mark location with ‘X’ and number each wound

Date referred to:

TVN …………….Physiotherapist…………….

Podiatrist………………Dietician……………...

Other (i.e. D/Nurse)………………………….

Assessors signature: ………………………..

Date: ………………………..…………………...

Ophthalmology Tissue Viability Link Nurse Tracy Culkin Complete on initial assessment and thereafter complete at every dressing change

Date of Assessment Number of woundAnalgesia required(Refer to local pain assessment tool)

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

Regular/ongoing analgesiaPre-dressing onlyWound Dimensions (enter size)Length (cm/mm)Width (cm/mm)Depth (cm/mm)Or trace wound circumferenceIs wound tracking/underminingPhotographyTissue type on wound bed ( enter percentages)Necrotic (Black)Sloughy (Yellow/Green)Granulating (Red)Epithelialising (Pink)Hypergranulating (Red)HaematomaBone/tendonWound exudate levels/ type (tick all relevant boxes)LowModerateHigh *Serous (Straw)Haemoserous (Red/Straw)Purulent (Green/Brown/Yellow)*Peri-wound skin (tick relevant boxes)Macerated (White)Oedematous *Erythema (Red)*Excoriated (Red)FragileDry/scalyHealthy/intactSigns of Infection * 1 or more of these signs may indicate possible infection Heat *New slough/necrosis(deteriorating wound bed)*Increasing pain*Increasing exudate*Increasing odour*Friable granulation tissue*Treatment objectives (tick relevant box)DebridementAbsorptionHydrationProtectionPalliative / conservativeReduce bacterial load

Ophthalmology Tissue Viability Link Nurse Tracy Culkin

Wound Treatment Plan and Evaluation of Care Patient Label

To be completed when treatment or dressing type / regime alteredNB Please write clearly

Date Wound Number

Cleansing Method, Dressing Choice & Rationale

Frequency Evaluation & Rationale for changing dressing type

Signature

Ophthalmology Tissue Viability Link Nurse Tracy Culkin Evaluation of Pressure Care Patient Label

To be completed on assessmentNB Please write clearly

Date Braden Score

Method of Pressure Relief

dressing/Cushion/ Overlay

FrequencyOf

Positioning

Rationale for changing patients position and patient aftercare on

discharge

Signature